<html><head>

        <title>Formulir Data Penduduk</title> 
        <link href="<?php echo base_url('assets/css/formpenduduk.css'); ?>" rel="stylesheet" type="text/css" />
        <link href="<?php echo base_url('assets/js/jquery-ui.css'); ?>" rel="stylesheet" type="text/css" />
        <script type="text/javascript" src="<?php echo base_url('assets/js/jquery-1.9.1.js'); ?>"></script>
        <script type="text/javascript" src="<?php echo base_url('assets/js/jquery-ui.js'); ?>"></script>

        <style type="text/css">
            <!--
            .style1 {color: #F0F0F0}
            .style2 {font-size: 24px}
            -->
        </style>
        <script type="text/javascript">
            $(function() {
                $("#tgl_lahir").datepicker({changeMonth: true, changeYear: true});
            });
        </script>
    </head>
    <body>
        <form action="<?php echo base_url('penduduk/tambah'); ?>" method="post">
            <table width="715" border="0" align="center">
                <tr>
                    <td colspan="8" class="trheader"><strong>Formulir Data Penduduk</strong></td>
                </tr>
                <tr>
                    <td colspan="8" class="jeda"><strong>Data Personal Penduduk </strong></td>
                </tr>
                <tr>
                    <td width="112">NIK</td>
                    <td colspan="3"><input type="text" name="nik" id="nik" class="textinput" placeholder="3501061411910002"/></td>
                    <td width="5">&nbsp;</td>
                    <td width="121">Nama</td>
                    <td colspan="2"><input type="text" name="nama" id="nama" class="textinput" placeholder="Niken Larasati" /></td>
                </tr>
                <tr>
                    <td>Tempat Lahir</td>
                    <td colspan="3"><input type="text" name="tmp_lahir" id="tmp_lahir" class="textinput" placeholder="Pacitan"/></td>
                    <td>&nbsp;</td>
                    <td>Tanggal Lahir</td>
                    <td colspan="2">&nbsp;&nbsp;&nbsp;<input type="text" name="tgl_lahir" id="tgl_lahir" /></td>
                </tr>
                <tr>
                    <td>Jenis Kelamin</td>
                    <td colspan="3">
                        <input name="jk" type="radio" value="L" id="L" class="radiobutton" />Laki-laki
                        <input name="jk" type="radio" value="P" id="P" class="radiobutton" />Perempuan</td>
                    <td>&nbsp;</td>
                    <td>Golongan darah</td>
                    <td colspan="2"><select name="gol_darah" id="gol_darah" class="list">
                            <option value="A">A</option>
                            <option value="B">B</option>
                            <option value="O">O</option>
                            <option value="AB">AB</option>
                            <option value="-">-</option>
                        </select></td>
                </tr>
                <tr>
                    <td>Pendidikan Akhir</td>
                    <td colspan="3"><select name="pdd" id="pdd" class="list">
                            <option value="1">-</option>
                            <option value="2">SD/Sederajat</option>
                            <option value="3">SLTP/Sederajat</option>
                            <option value="4">SLTA/Sederajat</option>
                            <option value="5">Diploma/Sederajat</option>
                            <option value="6">Strata/Sederajat</option>
                        </select></td>
                    <td>&nbsp;</td>
                    <td>Pekerjaan</td>
                    <td colspan="2"><select name="pekerjaan" id="pekerjaan" class="list">
                            <option value="1">Mahasiswa</option>
                            <option value="2">PNS</option>
                            <option value="3">Swasta</option>
                            <option value="0">-</option>
                        </select></td>
                </tr>
                <tr>
                    <td>Agama</td>
                    <td colspan="3"><select name="agama" id="agama" class="list">
                            <option value="1" selected>Islam</option>
                            <option value="2">Kristen Katolik</option>
                            <option value="3">Kristen Protestan</option>
                            <option value="4">Hindu</option>
                            <option value="5">Budha</option>
                            <option value="6">Konghuchu</option>
                            <option value="7">Kepercayaan</option>
                        </select></td>
                    <td>&nbsp;</td>
                    <td>Kewarganegaraan</td>
                    <td colspan="2"><select name="kwn" id="kwn" class="list">
                            <option value="WNI">WNI</option>
                            <option value="WNA">WNA</option>
                        </select></td>
                </tr>
                <tr>
                    <td>Status Perkawinan</td>
                    <td colspan="3"><select name="statuspk" id="statuspk" class="list">
                            <option value="1">Kawin</option>
                            <option value="2">Belum Kawin</option>
                        </select></td>
                    <td>&nbsp;</td>
                    <td> Status dalam Keluarga</td>
                    <td colspan="2"><select name="hubkel" id="hubkel" class="list">
                            <option value="1">Kepala Keluarga</option>
                            <option value="2">Istri</option>
                            <option value="3">Anak</option>
                            <option value="4">Menantu</option>
                            <option value="5">Cucu</option>
                        </select></td>
                </tr>
                <tr>
                    <td>Status Menetap</td>
                    <td colspan="3">
                        <input name="status" type="radio" value="A" id="A" class="radiobutton" />Aktif
                        <input name="status" type="radio" value="N" id="N" class="radiobutton" />Non-Aktif                    </td>
                    <td>&nbsp;</td>
                    <td>Telp</td>
                    <td colspan="2"><input type="text" name="no_telp" id="no_telp" class="textinput" placeholder="089761976713"/></td>
                </tr>
                <tr>
                    <td>Nama Ayah</td>
                    <td colspan="3"><input type="text" name="nama_ayah" id="nama_ayah" class="textinput" placeholder="Supeni"/></td>
                    <td>&nbsp;</td>
                    <td>Nama Ibu</td>
                    <td colspan="2"><input type="text" name="nama_ibu" id="nama_ibu" class="textinput" placeholder="Sumarni"/></td>
                </tr>
                <tr>
                    <td colspan="8">&nbsp;</td>
                </tr>
                <tr>
                    <td colspan="8" class="jeda"><strong>Data Dokumen Penduduk</strong></td>
                </tr>
                <tr>
                    <td>No. Kartu Keluarga</td>
                    <td colspan="3"><input type="text" name="kk" id="kk" class="textinput" placeholder="3501062001053536"/></td>
                    <td>&nbsp;</td>
                    <td>No. Surat Nikah</td>
                    <td colspan="2"><input type="text" name="no_nikah" id="no_nikah" class="textinput" placeholder=""/></td>
                </tr>
                <tr>
                    <td>&nbsp;</td>
                    <td colspan="3">&nbsp;&nbsp;&nbsp;<input type="button" name="carikk" id="carikk" value="Cari Data KK" class="radiobutton-kiri"/></td>
                    <td>&nbsp;</td>
                    <td>Tanggal Nikah</td>
                    <td colspan="2"><input type="text" name="tgl_nikah" id="tgl_nikah" class="textinput" placeholder=""/></td>
                </tr>
                <tr>
                    <td>No. Paspor</td>
                    <td colspan="3"><input type="text" name="paspor" id="paspor" class="textinput" placeholder=""/></td>
                    <td>&nbsp;</td>
                    <td>No. Surat Cerai</td>
                    <td colspan="2"><input type="text" name="no_cerai" id="no_cerai" class="textinput" placeholder=""/></td>
                </tr>
                <tr>
                    <td>No. Kitas</td>
                    <td colspan="3"><input type="text" name="kitas" id="kitas" class="textinput" placeholder=""/></td>
                    <td>&nbsp;</td>
                    <td>Tanggal Cerai</td>
                    <td colspan="2"><input type="text" name="tgl_cerai" id="tgl_cerai" class="textinput" placeholder=""/></td>
                </tr>
                <tr>
                    <td>&nbsp;</td>
                    <td width="69">&nbsp;</td>
                    <td width="77">&nbsp;</td>
                    <td width="79">&nbsp;</td>
                    <td>&nbsp;</td>
                    <td>&nbsp;</td>
                    <td width="83">&nbsp;</td>
                    <td width="135">&nbsp;</td>
                </tr>
                <tr>
                    <td colspan="4">
                        <input type="submit" name="tambah" id="tambah" value="Tambah" class="radiobutton-kiri"/>      
                        <input type="submit" name="ubah" id="ubah" value="Ubah" class="radiobutton-kiri" /></td>
                    <td>&nbsp;</td>
                    <td>&nbsp;</td>
                    <td><input type="submit" name="lihat" id="lihat" value="Lihat Data" class="radiobutton-kiri" /></td>
                    <td>&nbsp;</td>
                </tr>
            </table>
        </form>
    </body>
</html>
